Incidence and predictors of prolonged hemodynamic depression after carotid artery stenting: Yet another benefit of statins?

Risk Factors for Hemodynamic Depression After Carotid Stenting

BACKGROUND

The effects of different stents and morphology of the stenosis on hemodynamic depression (HD) and in-stent restenosis (ISR) are unclear after carotid artery stenting.

METHODS

142 patients were retrospectively enrolled and stratified into straight stent and tapered stent (TS), and further stratified according to stenosis morphology to compare the differences in final events. Logistic analysis was used to determine the risk factors for the occurrence of HD.

RESULTS

TS had a lower incidence of postprocedural HD (38.8% vs. 60.0%; P = 0.012) and 1-year ISR (1.5% vs. 8.0%; P = 0.078). In centripetal stenosis, there was no significant difference in postprocedural HD between the different stents (27.3% vs. 47.8%; P = 0.155). In contrast, for eccentric stenosis, TS was associated with a reduced risk of postprocedural HD (42.2% vs. 67.3%; P = 0.013). Logistic analyses found that eccentric stenosis (odds ratio [OR] = 2.561; 95% confidence interval [CI] = 1.100-5.965; P = 0.029), high-echo plaque (OR = 5.877; 95% CI = 1.472-23.462; P = 0.012), open-cell stent (OR = 3.173; 95% CI = 1.067-9.436; P = 0.038), and distal diameter of stent (OR = 1.541; 95% CI = 1.104-2.153; P = 0.011) were risk factors for postprocedural HD. The following factors were identified as risk factors for persistent hemodynamic depression: high-echo plaque (OR = 7.605; 95% CI = 2.105-27.468; P = 0.002) and open-cell stent (OR = 7.017; 95% CI = 1.384-35.583; P = 0.019); additionally, the further the minimum lumen distance from the carotid bifurcation, the lower the risk of persistent hemodynamic depression (OR = 0.942; 95% CI = 0.894-0.992; P = 0.024).

CONCLUSIONS

TS reduces the risk of postoperative HD and there is a trend toward a lower risk of ISR at 1 year after the procedure. Eccentric stenosis, high-echo plaque, open-cell stent, and distal diameter of stent are high-risk factors for HD.

Incidence and risk factors for hypotension after carotid artery stenting: Systematic review and meta-analysis

OBJECTIVE

Hypotension is recognized as a common complication after carotid artery stenting, but its incidence and the risk factors associated with it are uncertain. Therefore, we performed a systematic review and meta-analysis to investigate and identify risk factors for hypotension after surgery.

METHODS

We retrieved risk factors from eight databases for case-control and cross-sectional studies of hypotension after carotid artery stenting according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines on 28 November 2022. Data were analyzed by using R4.2.1 and Review Manager 5.3.

RESULTS

A total of 2843 samples were searched, and 17 publications were included in the analysis. The meta-analysis results showed that the incidence of hypotension after surgery was 28.6% (95% confidence interval [CI] (0.225, 0.347)). Age ⩾ 65 years (odds ratio [OR] = 4.55, 95% CI (2.50, 8.29), P < 0.00001), stenosis site (bulb) (OR = 4.41, 95% CI (2.50, 7.79), P < 0.00001), severe stenosis (OR = 3.56, 95% CI (1.62, 7.85), P = 0.002), stenosis proximity (⩽ 10 mm) to bifurcation (OR = 2.69, 95% CI (1.74, 4.15), P < 0.00001), calcified plaques (OR = 4.64, 95% CI (1.93, 11.14), P = 0.0006), post-balloon dilation (OR = 5.95, 95% CI (2.31, 15.31), P = 0.0002), bilateral carotid stenting (OR = 30.51, 95% CI (2.33, 399.89), P = 0.009), and intravenous fluid intake/mL on the first postoperative day (mean difference = 444.99, 95% CI (141.40, 748.59), P = 0.004) were risk factors for hypotension after surgery.

CONCLUSIONS

A high incidence of hypotension was observed after carotid artery stenting. Age, stenosis site, severe stenosis, stenosis proximity to bifurcation, calcified plaques, post-balloon dilation, type of surgery, and intravenous fluid intake were identified as risk factors.

Effect of Statin on Radiographic and Clinical Outcomes of Intracranial Aneurysms Treated With Pipeline Embolization: A Propensity Score-Matched Analysis

BACKGROUND AND OBJECTIVES

Studies have shown that use of statin can improve radiographic and clinical outcomes in patients receiving treatment for coronary artery or peripheral vascular stenosis. Statins are thought to be effective by reducing arterial wall inflammation. The same mechanism may have an influence on the efficacy of pipeline embolization device (PED) for intracranial aneurysm treatment. Although this question has been of interest, there is a lack of well-controlled data in the literature. The objective of this study is to analyze the effect of statins on outcomes of aneurysms treated with pipeline embolization through propensity score matching.

METHODS

Patients who underwent PED for unruptured intracranial aneurysms at our institution between 2013 and 2020 were identified. Patients on statin treatment vs those who were not were matched through propensity score by controlling for confounding factors including age, sex, current smoking status, diabetes, aneurysm morphology, volume, neck size, location of aneurysm, history of treatment for the same aneurysm, type of antiplatelet therapy, and elapsed time at last follow-up. Occlusion status at first follow up and last follow-up, and incidence of in-stent stenosis and ischemic complications during the follow-up period were extracted for comparison.

RESULTS

In total, 492 patients with PED were identified, of whom 146 were on statin therapy and 346 were not. After one-to-one nearest neighbor matching, 49 cases in each group were compared. At last follow-up, 79.6%, 10.2%, and 10.2% of cases in the statin therapy group and 67.4%, 16.3%, and 16.3% in the nonstatin group were noted to have Raymond-Roy 1, 2, and 3 occlusions, respectively ( P = .45). No significant difference was observed in immediate procedural thrombosis ( P > .99), long-term in-stent stenosis ( P > .99), ischemic stroke ( P = .62), or retreatment ( P = .49).

CONCLUSION

Statin use does not affect occlusion rate or clinical outcomes in patients treated with PED treatment for unruptured intracranial aneurysms.

Relationship between annular calcification of plaques in the carotid sinus and perioperative hemodynamic disorder in carotid angioplasty and stenting

OBJECTIVE

To investigate the correlation between annular plaque calcification in the carotid sinus and perioperative hemodynamic disorder (HD) in carotid angioplasty and stenting (CAS).

METHODS

The clinical data of 49 patients undergoing CAS due to narrowing of the carotid sinus were retrospectively analyzed. All patients had preoperative carotid computed tomography angiography (CTA) and were divided into HD and non-HD groups based on the occurrence of HD in the perioperative period of CAS. HD was defined as persistent bradycardia (heart rate < 60 beats per min) or persistent hypotension (systolic blood pressure < 90 mmHg) in the perioperative period and lasting for at least 1 h. The baseline data, including the degree of carotid artery stenosis, plaque length, plaque thickness, calcified plaque morphologies (i.e., plaque circumferential angle: < 90° defined as dotted calcification; 90°-180° defined as arcuate calcification; > 180° defined as annular calcification), contralateral carotid artery conditions, balloon diameter, and stent types, were compared between the two groups. Binary logistic regression was used to analyze the risk factors for the occurrence of HD.

RESULTS

Among the 49 patients undergoing CAS, 14 (28.57%) developed perioperative HD, and 35 did not. Annular calcification was more common in the patients in the HD group than in the non-HD group. No significant differences in the probabilities of dotted and arcuate calcifications were found between the two groups (p > 0.05). The duration of continuous dopamine consumption in the HD group was 9-71 h. The average hospital stay of the HD group (10.14 ± 4.17 days) was significantly longer than that of the non-HD group (6.57 ± 1.9 days; p < 0.001). Patients in the HD group had significantly more pronounced lumen stenosis (p = 0.033) and longer plaque length (p = 0.034) than those in the non-HD group. After adjusting for age and sex, multivariate regression analysis showed that the presence of annular plaque calcification was an independent predictor of HD (odds ratio: 7.68, 95% confidence interval: 1.46-40.37, p = 0.016).

CONCLUSIONS

The occurrence of annular plaque calcification in the carotid sinus was an independent risk factor for perioperative HD in CAS. Preoperative carotid CTA assists with the early identification of high-risk patients who may develop HD.